The Anesthesiology Milestones 2.0: An Improved Competency-Based Assessment for Residency Training

Ambardekar, Aditee P. MD, MSEd^*; Walker, K. Karisa MD, MEd^†; McKenzie-Brown, Anne Marie MD^‡; Brennan, Kaitlyn DO, MPH^§; Jackson, Chelsia MD^∥; Edgar, Laura EdD, CAE^¶; Ellinas, Herodotos MD, MHPE^#; Long, Timothy R. MD^**; Trombetta, Carlos E. MD^††; Laskey, Martin G. DO^‡‡; Wargo, Bradley W. DO^§§; Dainer, Rupa J. MD^∥∥; Draconi, Crys S. BA^¶¶; Mitchell, John D. MD^##

Author Information

From the ^*Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas

^†Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania

^‡Department of Anesthesiology, Emory University, Atlanta, Georgia

^§Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee

^∥Department of Anesthesiology, LAC + USC Medical Center, Keck School of Medicine of the University of Southern California, Los Angeles, California

^¶Accreditation Council for Graduate Medical Education, Chicago, Illinois

^#Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin

^**Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota

^††Anesthesiology Institute

^‡‡Department of Anesthesiology and Pain Management, Cleveland Clinic, Cleveland, Ohio

^§§Kansas Health Science Center, OrthoSouth-Crosstown Back & Pain Institute, Wichita, Kansas

^∥∥Pediatric Specialists of Virginia, Fairfax, Virginia

^¶¶Women’s Health Institute, Cleveland Clinic, Cleveland, Ohio

^##Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Published ahead of print 25 March 2021.

Accepted for publication February 5, 2021.

Funding: None.

The authors declare no conflicts of interest.

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Reprints will not be available from the authors.

Address correspondence to John D. Mitchell, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215. Address e-mail to [email protected].

Anesthesia & Analgesia 133(2):p 353-361, August 2021. | DOI: 10.1213/ANE.0000000000005499

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Abstract

See Article, p 349

Graduate medical education (GME) has been evolving from time- and structure-based training to competency-based training over the past 3 decades. The time- and structure-based training with which most of us are familiar dates back to the Flexner^¹ report of 1910. Flexner^¹ was an educator and philosopher charged with surveying the state of medical education at the turn of the 20th century and giving recommendations for its standardization and improvement. It was at this time that medical school curricula were standardized with respect to content and time. Medical education was also linked to experiential activities now known as clerkships, and the growing concept arose that medical educators and faculty were responsible for scientific advancement by way of biomedical research.

The notion of competency and how it should be defined and measured was introduced in medicine and other fields in the latter part of the 20th century. There was a wide range of societal and professional forces behind this movement, but widespread adoption proved challenging.^² Preventive medicine and neurosurgery were among the first adopters of competency-based programs and described the consensus-building processes and resultant decrease in time to surgical skill acquisition, respectively.^³^,^⁴ The overarching theme in competency-based literature of this time was developing valid evaluations of skill acquisition. Nonetheless, the Flexnerian revolution of the 21st century represented an earnest attempt to redefine medical education in the context of competency.^²

The Accreditation Council for Graduate Medical Education (ACGME) jointly with the American Board of Medical Specialties (ABMS) first endorsed the 6 core competencies—patient care, medical knowledge, practice-based learning and improvement (PBLI), interpersonal and communication skills (ICS), professionalism (PROF), and systems-based practice (SBP)—as part of the Outcomes Project, an initiative born out of a commitment to demonstrate to the public that the GME community was producing competent physicians who could work independently and effectively within a health care delivery system.^⁵ Despite significant effort to encourage and facilitate assessment development within the domains of the Outcomes Project across GME, the quality of data collected and, thus, outcome measures were not usable for accreditation standards and public accountability.^⁶^,^⁷

The shortcomings from the Outcomes Project informed the development of the Milestones. Beginning in 2009, each specialty community was asked to develop their own rubrics of subcompetencies with sequential 5-level Milestones within the 6 core-competency domains (Figure 1). These Milestones described the range of observable behaviors from matriculation into the specialty (level 1) to an expert or aspirational level (level 5) that only exceptional residents would achieve. In this system, behaviors expected at graduation were targeted at level 4. The launch of the Milestones Project began in July 2013 and continued the journey of outcome-based resident and programmatic assessment, encouraged self-regulation and peer review that inform lifelong learning, and endeavored to reduce the burden associated with structure- and time-based approaches to GME.

Figure 1.:
Milestone formatting and organization. Core competencies and subcompetencies are listed in the header. Each theme or developmental trajectory follows across a row. Each milestone is an important point along the developmental pathway.

Nearly a decade after embarking on the development of the Milestones, graduate medical educators have reconvened to develop and report on the second iteration of this outcome-based system. These updated milestones, effective July 1, 2021, can be found on the ACGME website (https://www.acgme.org/Portals/0/PDFs/Milestones/AnesthesiologyMilestones2.0.pdf?ver=2020-12-02-125500-287). This special article describes the lessons learned from the Anesthesiology Milestones 1.0 and the development of Milestones 2.0 for the specialty.

ANESTHESIOLOGY MILESTONES 1.0

The Anesthesiology Milestones 1.0 Committee was comprised of key stakeholders from the ACGME, the American Board of Anesthesiology, Anesthesiology residency training programs, and a resident representative. The 9-member group convened in 2012 and began an iterative process to ultimately develop 25 unique Milestones that spanned the 6 core competencies.^⁸ The primary purpose of these Milestones was 2-fold: to assess whether trainees were meeting core-competency goals along a trajectory as they progressed through residency and to help programs identify gaps in curricula and assessments.

Schartel et al^⁸ described a commitment to balance comprehensiveness of assessment with practicality. The committee considered the potential workload that Milestone evaluation would place on program leadership and Clinical Competency Committees (CCCs). Table 1 shows the breakdown of Milestones within the 6 core competencies. Following a pilot involving 20 residency programs, these Milestones were formally implemented in July 2014.

Table 1. - Comparison Between Milestones 1.0 and Milestones 2.0 in the Number of Milestones per Competency

Competency	Milestones 1.0	Milestones 2.0
Patient care	10	10
Medical knowledge	1	2
Professionalism	5	3
Interpersonal and communication skills	3	3
Practice-based learning and improvement	4	2
Systems-based practice	2	3
Total	25	23

There were challenges and limitations to the development and implementation of Milestones 1.0 across all specialties. As expected, there was substantial variability in definitions, content, and the expected developmental progression among specialties.^⁹ These inconsistencies made it difficult to validate and share assessment strategies and create efficient faculty development programs for educators across specialties.^¹⁰ The inability to compare progression across specialties also limited the ability to identify areas that would benefit from cross specialty collaborative development of novel approaches to teaching. Additionally, the ACGME noted a tendency within Anesthesiology to “straight line” Milestone evaluations, making Anesthesiology an outlier in their reporting of Milestones. This describes evaluations submitted where the developmental stage identified for each individual resident mirrors the training year for each subcompetency.^¹¹ Straightlining runs counter to the notion that trainees progress at differing rates and may achieve independent practice at earlier or later stages than their peers but may be happening for a number of reasons. The original Milestones were written with guidance for reporting level based on year in training.^¹² This, in fact, reinforces how program directors and CCCs have been evaluating residents for decades—on a time-based continuum. Quite possibly, program directors may also be wary to show slow progression of their trainees to protect accreditation or reputation of their program.^¹³ It should be emphasized that programmatic Milestones data are not shared with the Review Committees for accreditation purposes, rather resident performance is aggregated at the national level and used to inform changes to curricula and assessment within specialties.

Nonetheless, the lack of substantial variability in the evaluations of Milestones submitted by many Anesthesiology programs has been instructive. It has highlighted that Anesthesiology Milestones need to be more intentionally written with the phenomenon of straightlining in mind. It also suggests that most programs have struggled to develop and implement metrics to adequately assess Milestones in practice and require additional support. Enhanced milestones and supplemental materials for programmatic support are necessary to achieve the end goal: to enable programs to place each resident on the Milestones rubric based on where they functionally are and not based on their year or level in training.

It was always expected that Milestones would evolve over time. Following the collection and review of data in 2016, the ACGME announced plans for the second iteration of the Milestones. Much quantitative and qualitative research has informed the Milestones revision process. In this process, the ACGME engaged a broader stakeholder community, looked to reduce the complexity of the Milestones, and concomitantly developed additional tools and resources to assist programs and institutions.^⁹

ANESTHESIOLOGY MILESTONES 2.0

The Process

The ACGME formed the Anesthesiology Milestones 2.0 working group following an open call for volunteers in October 2018 (Figure 2). The working group included representation from the American Board of Anesthesiology, the American Osteopathic Board of Anesthesiology, the American Society of Anesthesiologists, the American Osteopathic College of Anesthesiologists, the Association of Anesthesiology Core Program Directors, the Society for Education in Anesthesia, and the ACGME Review Committee for Anesthesiology. The group consisted of both allopathic and osteopathic physicians from diverse geographic locations had 1 resident member and 1 public member, and included private practice and academic physicians with diverse subspecialty expertise. The working group membership was finalized in December 2018.

In January 2019, all Anesthesiology program directors and program coordinators received a survey to assess the utility of the Milestones contained in the Medical Knowledge and Patient Care competencies and to inform the working group of content to retain, remove, or add during the development of Milestones 2.0. They were asked to rate their level of agreement with statements that each of the original Patient Care and Medical Knowledge Milestones: (1) represent a realistic progression of knowledge, skills, and behavior, (2) discriminate between meaningful levels of competency, (3) should be edited, (4) should be deleted, (5) should include additional skills, and (6) enable evaluation of their resident’s skills.

Before the initial in-person meeting, the ACGME provided working group members with an extensive library of preparatory materials for review. The initial meeting of the working group was held in October 2019. This 1.5-day meeting included a review of the Milestone framework, reported Milestone data, survey data obtained from stakeholders in January, and relevant research publications. The group discussed what graduates of the specialty would look like in 2025 to determine the essential subcompetencies for tomorrow’s graduates. The working group used this framework to construct an outline of potential Milestones that may be considered essential for graduates in Anesthesiology.

The 25 original Milestones became the framework for assessing resident development and competence. Extensive review of the original Milestones and analysis of the survey data identified several important patterns. In addition to there being too many Milestones, stakeholders felt there were too many items within each Milestone. The language to describe these was a complex mixture of positive and negative verbiages that added confusion. There was not only a notable absence of critical skills such as vigilance, prioritization, and sterile technique but also a need to update with advances in our clinical practice. Changes in how anesthesiologists use point-of-care ultrasound (POCUS), incorporation of electronic medical records, and a better understanding of how personal electronic devices may be acceptably used needed incorporation into the next iteration.

To address those issues, each Milestone was revisited and revised. The preamble to the Milestones was edited to eliminate language regarding the correlation between training year level and Milestone level. With differences in training programs, timing of rotations, and individual skill sets, residents will be expected to achieve Milestones at their own pace and not necessarily track as a consistent cohort. For example, a resident who participates in a significant volume of POCUS procedures in internship may reach level 4 before they begin their clinical anesthesia 1 (CA1) year (patient care 6). A visual example of different rates of normal progression as compared to straightlining is provided in Figure 3. This variability in progression is expected and acceptable to the ACGME.

Figure 3.:
Straightlining/progression. This chart exemplifies different rates of normal progression as compared to straightlining. CA indicates clinical anesthesia; CBY, clinical base year; PGY, postgraduate year.

With the Milestone framework in place, the group began creation of subcompetencies within each Milestone. To ensure consistent methodology, the whole group completed all subcompetencies for 1 patient care Milestone and then divided up into small groups to create the remaining patient care and medical knowledge subcompetencies.

The working group met again in February 2020. The focus of the second meeting was to complete work on Milestones within the competencies of PROF, communication, SBP, and problem-based learning and improvement. The group also began work on the supplemental guide. The working group completed the supplemental guide for 1 Milestone with the purpose of creating a common framework for the remainder of the supplemental guide. The working group then divided into subgroups to complete the remainder of the guide. Following the meeting, working group members completed the remaining elements of the guidebook remotely, using a shared Google Drive and Google Docs (Google Inc, Mountain View, CA).

Due to the coronavirus disease 2019 (COVID-19) pandemic, the remaining study was completed over 4 virtual meetings. These meetings included finalization of Milestones, subcompetencies, and the supplemental guide. Working group members accessed material for review and made edits though shared files on Google Drive. The ACGME posted the final draft of 23 Milestones and the supplemental guide for public comment on August 20, 2020.

The Milestones

Table 1 summarizes the breakdown of the new Milestones within the 6 competencies as compared to the original Milestones. Milestones are characterized as either “specialty-specific” or “harmonized.” Milestones within the Patient Care and Medical Knowledge domains are “specialty-specific,” skills and knowledge that are unique to anesthesiology. Milestones within the other 4 competencies are described as “harmonized,” because they not only are universal competencies in all medical specialties but adapted across specialties in the process described below. No individual Milestone remained the same and many were combined or split. In general, all were described with simpler language and less ambiguous continuums of progression. Positive descriptors were used for consistency. Each Milestone was limited to 3 lines of skill, and each skill required 4 or 5 progressive levels to be included.

The Specialty-Specific Milestones

The working group was asked to consider the future of anesthesiology training, as these Milestones are intended to stand for the next 5 years. This resulted in 11 Patient Care Milestones and 2 Medical Knowledge Milestones. With advances in the use of technology, the group sought to develop ultrasound into its own Milestone and include its application in various settings: POCUS, transesophageal echocardiography (TEE), and regional anesthesia. The use of electronic devices in the operating room (OR), once strictly considered a distraction, now is considered a source of point-of-care, evidence-based practice aids.

Two particular additions worth highlighting are those of “Clinical Reasoning” (Medical Knowledge 2) and “Situational Awareness and Crisis Management” (Patient Care 7). Clinical Reasoning addresses the application of knowledge apart from “Foundational Knowledge” (Medical Knowledge 1) and incorporates reflective practice, a critical element of lifelong learning in medicine. Situational Awareness, an essential nontechnical skill for anesthesiologists, was absent from the first iteration of the Milestones. Including these elements will help provide a framework for CCCs to communicate more clearly with trainees when these areas need improvement.

Harmonized Milestones

Milestones within the other 4 competencies, SBP, PBLI, PROF, and ICS, are characterized as “harmonized” Milestones. They are universally expected of physicians, no matter the specialty whose language was developed after an in-depth, qualitative analysis across all ACGME-accredited specialties. Since these competencies are less specialty-specific and are relevant to all fields, any overlapping themes across specialties may be used to create common language in training and assessment. Edgar et al^¹⁰ performed a qualitative thematic analysis of the original Milestones within each of these competencies across 26 specialties to identify commonalities and identified 22 themes with modest overlap and variability.

A series of interdisciplinary, consensus-generating activities followed to develop a draft set of harmonized Milestones.^⁹ The results of this study provided a framework or a core set of themes from which working groups could customize Milestones, subcompetencies, and their development within their respective specialties (Figure 4). In general, the Milestones 2.0 working group came to the consensus that the harmonized language was relevant to the practice of anesthesiology. Notable Milestones that were specific to our field included accurate documentation in an anesthetic record to wholly document care and challenges in perioperative care within ICS 3, Communication with Health Care Systems. An example of an alteration was the focus on performance of safe and effective transitions, an activity in which anesthesiologists engage multiple times daily as part of SBP2, System Navigation for Patient-Centered Care.

Supplemental Guide

Significant time and effort were invested to deliberately develop the content and structure of a supplemental guide alongside the new Milestones. This guide is viewable on the ACGME website (https://www.acgme.org/Portals/0/PDFs/Milestones/AnesthesiologySupplementalGuide.pdf?ver=2020-12-02-142625-453). As its primary aim was to reduce ambiguity in interpretation and application of the Milestones, the committee provided familiar examples and assessment approaches to aid program directors and CCC members in assigning Milestone levels.

The content of the guide is based on the 6 core competencies, each of which is subsequently broken down into subcompetencies or Milestones. Each subcompetency is displayed in a consistent quinary fashion that: (1) describes the overall intent, (2) provides examples for each level, (3) lists assessment models and tools, (4) provides a space to map the curriculum, and (5) shares relevant notes and resources. The overall intent encapsulates the goal of the competency area, while examples serve to bring the subcompetencies into context. The examples provided for each level of development are new in the Milestones 2.0 Supplemental Guide and are meant to be dynamic. In creating the examples, the group presented a thematic scenario for the competencies and then developed a scene by escalating the example along the training level. Programs should use these scenarios as a guide and substitute their own examples based on the clinical milieu in their own institutions. The assessment tools are suggestions for methods to best assess performance in each area. At the end of the supplemental guide is a map that describes where subcompetencies from Milestones 1.0 can be found within the Milestones 2.0 framework (Table 2).

Table 2. - Map of Subcompetency Similarities Between Milestones 1.0 and Milestones 2.0

Milestones 1.0	Milestones 2.0
PC1: Pre-anesthetic Patient Evaluation, Assessment, and Preparation	PC1: Pre-anesthetic Evaluation
PC2: Anesthetic Plan and Conduct	PC2: Peri-operative Care and Management
PC2: Anesthetic Plan and Conduct	PC4: Intra-operative Care
PC3: Peri-procedural Pain Management	PC2: Peri-operative Care and Management
PC3: Peri-procedural Pain Management	PC11: Acute, Chronic, and Cancer Pain (non-reportable)
PC4: Management of Peri-anesthetic Complications	PC8: Post-operative Care
PC5: Crisis Management	PC7: Situational Awareness and Crisis Management
PC6: Triage and Management of the Critically Ill Patient in a Non-operative Setting	PC8: Post-operative Care
	PC9: Critical Care
PC7: Acute, Chronic, and Cancer-related Pain Consultation and Management	PC2: Peri-operative Care and Management
	PC6: Point-of-Care Ultrasound
PC8: Technical Skills: Airway Management	PC5: Airway Management
PC9: Technical Skills: Use and Interpretation of Monitoring and Equipment	PC3: Application and Interpretation of Monitors
PC10: Technical Skills: Regional Anesthesia	PC10: Regional (Peripheral and Neuraxial) Anesthesia
MK1: Knowledge of Biomedical, Clinical, Epidemiological, and Social-behavioral Sciences as Outlined in the American Board of Anesthesiology Content Outline	MK1: Foundational Knowledge
No match	MK2: Clinical Reasoning
SBP1: Coordination of Patient Care within the Health Care System	SBP2: System Navigation for Patient-centered Care
SBP2: Patient Safety and Quality Improvement	SBP1: Patient Safety and Quality Improvement
No match	SBP3: Physician Role in Health Care Systems
PBLI1: Incorporation of Quality Improvement and Patient Safety Initiatives into Personal Practice	SBP1: Patient Safety and Quality Improvement
PBLI2: Analysis of Practice to Identify Areas in Need of Improvement	PBLI2: Reflective Practice and Commitment to Personal Growth
PBLI3: Self-directed Learning	PBLI1: Evidence-based and Informed Practice
PBLI3: Self-directed Learning	PBLI2: Reflective Practice and Commitment to Personal Growth
PBLI4: Education of Patient, Families, Students, Residents, and Other Health Professionals	No match
PROF1: Responsibility to Patients, Families, and Society	PROF1: Professional Behavior and Ethical Principles
PROF2: Honesty, Integrity, and Ethical Behavior	PROF1: Professional Behavior and Ethical Principles
PROF3: Commitment to Institution, Department, and Colleagues	PROF2: Accountability/Conscientiousness
PROF4: Receiving and Giving Feedback	PBLI2: Reflective Practice and Commitment to Personal Growth
PROF5: Responsibility to Maintain Personal Emotional, Physical, and Mental Health	PROF2: Accountability/Conscientiousness
	PROF3: Self-Awareness and Well-being
ICS1: Communication with Patients and Families	ICS1: Patient and Family-centered Communication
ICS2: Communication with Other Professionals	ICS2: Interprofessional and Team Communication
ICS3: Team and Leadership Skills	ICS2: Interprofessional and Team Communication
No match	ICS3: Communication within Health Care Systems

These are not necessarily exact matches, but are areas that include some of the same elements. Inclusion or exclusion of any subcompetency does not change the educational value or impact on curricula or assessments.

Abbreviations: ICS, interpersonal and communication skills; MK, medical knowledge; PBLI, practice-based learning and improvement; PC, patient care; PROF, professionalism; SBP, systems-based practice.

The structure and design of the supplemental guide provide an area for programs to map their didactic and clinical curricula back to each of the Milestones. This is essential for programs to ensure that the learning experiences provided adequately address all of the Milestones during the course of training. The section on supplementary notes and resources provides miscellaneous information on best practices from the literature. This section can also be used by programs to help clarify questions or create action plans. Although great effort was taken by the committee to include relevant and up-to-date notes and resources, they are not intended to be exhaustive.

The supplemental guide is intended to be a living document customizable for each program. For example, an institution may be developing a longitudinal POCUS curriculum that builds on itself through the various critical care rotations and culminates in an objective structured clinical examination and capstone project. This curricular mapping and assessment tool should be listed to help core educators identify when and how the trainees can be evaluated. This can provide clarity and help to coordinate numerous faculty involved in evaluating trainees at various times in different clinical settings.

When up-to-date and relevant at the programmatic level, the supplemental guide should prove helpful to program directors and CCC members alike to inform committee discussions, resident assessments, and Milestone level assignments. Program coordinators and other administrative staff may use it to collect and organize relevant data ahead of CCC meetings. Ideally, application of the supplemental guide could also provide quality-improvement activities at the rotation or program level and direct development opportunities for core faculty as well.

Public Comment

Preliminary versions of both the Anesthesiology Milestones 2.0 and the Supplemental Guide were made available on August 20, 2020 to the community of stakeholders. Public comments from program directors, program coordinators, residents, and other members of the faculty were encouraged. Respondents were asked to rate their agreement on a Likert scale to 4 statements for each of the 23 Milestones that asked whether: (1) the Milestone presents a realistic progression of knowledge, skill, and behaviors, (2) the Milestone set discriminates between meaningful levels of competency, (3) the respondent knows how to assess the Milestone effectively, and (4) the supplemental guide is a useful resource in understanding this Milestone. A majority of respondents agreed or strongly agreed with each of these 4 statements for all of the 23 Milestones.

A few themes emerged from review of the public comments. Because of the variability of experiences among institutions and training programs, respondents had concerns that the working group included advanced monitoring techniques, invasive lines, and even rare emergencies by name in the Milestones and supplemental guide. The working group made sure to include in the Milestones language only aspects of training that were listed in the core program requirements.^¹⁴ Specific experiences or procedures listed in the supplemental guide were provided simply as examples to program directors, CCCs, and core faculty when appropriate.

Additionally, respondents shared concern for the inability to map individual Milestones achievements to postgraduate year (PGY) levels. For example, central line placement and TEE were both cited often as skills that usually occur in the PGY 3 year, which does not correspond well with how the Milestones are written. It has always been the goal of the Milestones Project that through the development of the competency-based rubrics trainees be provided developmental feedback on various skills throughout their training. Thus, emphasis was placed by the working group to write the second iteration of the Milestones to enable the assessment of individual trainees based on their skill progression rather than their time in training. An ability to do this is a first and crucial step in achieving a true competency-based system for GME.

There were several comments that the Milestones 2.0 was an overall improvement from the previous version and that the supplemental guide would prove a useful resource. Milestone development was and will continue to be a consensus-driven process that considers the feedback and experience from previous versions. Relevant data and experience from other specialties were considered and will also continue to be a factor in future iterations. Finally, the ACGME will invite 20 programs to complete an annual quality assurance (QA) survey intended to monitor the use and understanding of the Milestones. Results of the survey will identify areas that require additional faculty development and suggest changes to the Milestones and supplemental guide.

DISCUSSION

Limitations

While the authors attempted to always develop consensus and use best evidence in creating the new Milestones, there were some limitations. While experienced educators and end users from a wide range of programs, the authors were not universal content or assessment experts, and decisions were both data- and consensus-driven. Thus, there may be opportunities for future improvements as more data become available. Future advances in the field may also require updates and additions to these Milestones.

CONCLUSIONS

The Anesthesiology Milestones 2.0 Project aims to develop simpler, clearer, and more directly applicable Milestones. The reduced number of subcompetencies, continuity of each competency across levels, and simplification of language should aid in the clarity of these Milestones. The supplemental guide is designed to provide a roadmap for implementation and assessment as well. While it is anticipated that the Milestones will continue to undergo iterative changes over time, this first major improvement should enhance the usability of the system substantially. The Milestones that are shared by all specialties in medicine, the harmonized Milestones, may also enable collaboration and facilitation of meaningful research across all specialties. Shared research will be of particular importance in driving development of assessment tools that have universal utility, which is something that many programs have requested. Milestones 2.0 is the culmination of a community effort at improvement both within and across specialties with continued growth and development of the Milestones and associated materials over time. The new Milestones will be in use for the 2021–2022 academic year.

ACKNOWLEDGMENTS

The authors wish to acknowledge the contributions of Ms Vanessa Wong, Project Coordinator for the Center for Education Research, Technology, and Innovation in the Department of Anesthesia, Critical Care and Pain Medicine at Beth Israel Deaconess Medical Center for the preparation of figures and tables and formatting of the article.